J Korean Med Sci.  2022 Oct;37(42):e305. 10.3346/jkms.2022.37.e305.

Comparison of Factors Associated With Direct Versus Transferred-in Admission to Government-Designated Regional Centers Between Acute Ischemic Stroke and Myocardial Infarction in Korea

  • 1Busan Regional Cardiocerebrovascular Disease Center, Dong-A University Hospital, Busan, Korea
  • 2Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
  • 3Gyeonggi Regional Cardiocerebrovascular Disease Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
  • 4Gangwon Regional Cardiocerebrovascular Disease Center, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, Korea
  • 5Incheon Regional Cardiocerebrovascular Disease Center, Inha University College of Medicine, Incheon, Korea
  • 6Daegu-Gyeongbuk Regional Cardiocerebrovascular Disease Center, Kyungpook National University Hospital, Daegu, Korea
  • 7Gyeongnam Regional Cardiocerebrovascular Disease Center, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
  • 8Jeonbuk Regional Cardiocerebrovascular Center, Wonkwang University Hospital, Iksan, Korea
  • 9Gwangju-Jeonnam Regional Cardiocerebrovascular Disease Center, Chonnam National University Medical School and Hospital, Gwangju, Korea
  • 10Jeju Regional Cardiocerebrovascular Disease Center, Jeju National University Hospital, Jeju, Korea
  • 11Daejeon-Chungnam Regional Cardiocerebrovascular Disease Center, Hospital and College of Medicine, Chungnam National University, Daejeon, Korea
  • 12Chungbuk Regional Cardiocerebrovascular Disease Center, Chungbuk National University and Hospital, Cheongju, Korea
  • 13Department of Preventive Medicine, School of Medicine, Konkuk University, Seoul, Korea


There has been no comparison of the determinants of admission route between acute ischemic stroke (AIS) and acute myocardial infarction (AMI). We examined whether factors associated with direct versus transferred-in admission to regional cardiocerebrovascular centers (RCVCs) differed between AIS and AMI.
Using a nationwide RCVC registry, we identified consecutive patients presenting with AMI and AIS between July 2016 and December 2018. We explored factors associated with direct admission to RCVCs in patients with AIS and AMI and examined whether those associations differed between AIS and AMI, including interaction terms between each factor and disease type in multivariable models. To explore the influence of emergency medical service (EMS) paramedics on hospital selection, stratified analyses according to use of EMS were also performed.
Among the 17,897 and 8,927 AIS and AMI patients, 66.6% and 48.2% were directly admitted to RCVCs, respectively. Multivariable analysis showed that previous coronary heart disease, prehospital awareness, higher education level, and EMS use increased the odds of direct admission to RCVCs, but the odds ratio (OR) was different between AIS and AMI (for the first 3 factors, AMI > AIS; for EMS use, AMI < AIS). EMS use was the single most important factor for both AIS and AMI (OR, 4.72 vs. 3.90). Hypertension and hyperlipidemia increased, while living alone decreased the odds of direct admission only in AMI; additionally, age (65–74 years), previous stroke, and presentation during non-working hours increased the odds only in AIS. EMS use weakened the associations between direct admission and most factors in both AIS and AMI.
Various patient factors were differentially associated with direct admission to RCVCs between AIS and AMI. Public education for symptom awareness and use of EMS is essential in optimizing the transportation and hospitalization of patients with AMI and AIS.


Acute Ischemic Stroke; Myocardial Infarction; Transferred-in; Cardiocerebrovascular Center


1. O’Gara PT, Kushner FG, Ascheim DD, Casey DE Jr, Chung MK, de Lemos JA, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol. 2013; 61(4):e78–140. PMID: 23256914.
2. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019; 50(12):e344–e418. PMID: 31662037.
3. Meretoja A, Roine RO, Kaste M, Linna M, Roine S, Juntunen M, et al. Effectiveness of primary and comprehensive stroke centers: PERFECT stroke: a nationwide observational study from Finland. Stroke. 2010; 41(6):1102–1107. PMID: 20395609.
4. Mullen MT, Branas CC, Kasner SE, Wolff C, Williams JC, Albright KC, et al. Optimization modeling to maximize population access to comprehensive stroke centers. Neurology. 2015; 84(12):1196–1205. PMID: 25740858.
5. Kim J, Hwang YH, Kim JT, Choi NC, Kang SY, Cha JK, et al. Establishment of government-initiated comprehensive stroke centers for acute ischemic stroke management in South Korea. Stroke. 2014; 45(8):2391–2396. PMID: 24994720.
6. Cho SG, Kim Y, Choi Y, Chung W. Impact of regional cardiocerebrovascular centers on myocardial infarction patients in Korea: a fixed-effects model. J Prev Med Public Health. 2019; 52(1):21–29. PMID: 30742758.
7. Ali SF, Fonarow G, Liang L, Xian Y, Smith EE, Bhatt DL, et al. Rates, characteristics, and outcomes of patients transferred to specialized stroke centers for advanced care. Circ Cardiovasc Qual Outcomes. 2018; 11(9):e003359. PMID: 30354551.
8. Vora AN, Peterson ED, Hellkamp AS, Sutton NR, Panacek E, Thomas L, et al. Care transitions after acute myocardial infarction for transferred-in versus direct-arrival patients. Circ Cardiovasc Qual Outcomes. 2016; 9(2):109–116. PMID: 26812934.
9. Kim JY, Lee KJ, Kang J, Kim BJ, Kim SE, Oh H, et al. Acute stroke care in Korea in 2013-2014: national averages and disparities. J Korean Med Sci. 2020; 35(20):e167. PMID: 32449325.
10. Choi JC, Kim JG, Kang CH, Bae HJ, Kang J, Lee SJ, et al. Effect of transport time on the use of reperfusion therapy for patients with acute ischemic stroke in Korea. J Korean Med Sci. 2021; 36(11):e77. PMID: 33754510.
11. Kawecki D, Gierlotka M, Morawiec B, Hawranek M, Tajstra M, Skrzypek M, et al. Direct admission versus interhospital transfer for primary percutaneous coronary intervention in ST-segment elevation myocardial infarction. JACC Cardiovasc Interv. 2017; 10(5):438–447. PMID: 28216215.
12. Kang J, Kim SE, Park HK, Cho YJ, Kim JY, Lee KJ, et al. Routing to endovascular treatment of ischemic stroke in Korea: recognition of need for process improvement. J Korean Med Sci. 2020; 35(41):e347. PMID: 33107228.
13. Nickles AV, Roberts S, Shell E, Mitchell M, Hussain S, Lyon-Callo S, et al. Characteristics and outcomes of stroke patients transferred to hospitals participating in the Michigan Coverdell acute stroke registry. Circ Cardiovasc Qual Outcomes. 2016; 9(3):265–274. PMID: 27072678.
14. Gurwitz JH, Goldberg RJ, Malmgren JA, Barron HV, Tiefenbrunn AJ, Frederick PD, et al. Hospital transfer of patients with acute myocardial infarction: the effects of age, race, and insurance type. Am J Med. 2002; 112(7):528–534. PMID: 12015243.
15. Kim RB, Hwang JY, Park HW, Her AY, Lee JH, Kim MH, et al. Contemporary status of acute myocardial infarction in Korean patients: Korean registry of acute myocardial infarction for regional cardiocerebrovascular centers. J Clin Med. 2021; 10(3):498. PMID: 33535380.
16. Knol MJ, VanderWeele TJ. Recommendations for presenting analyses of effect modification and interaction. Int J Epidemiol. 2012; 41(2):514–520. PMID: 22253321.
17. Ali SF, Singhal AB, Viswanathan A, Rost NS, Schwamm LH. Characteristics and outcomes among patients transferred to a regional comprehensive stroke center for tertiary care. Stroke. 2013; 44(11):3148–3153. PMID: 24021682.
18. Zachrison KS, Onnela JP, Reeves MJ, Hernandez A, Camargo CA Jr, Zhao X, et al. Hospital factors associated with interhospital transfer destination for stroke in the Northeast United States. J Am Heart Assoc. 2020; 9(1):e011575. PMID: 31888430.
19. Park YH, Kang GH, Song BG, Chun WJ, Lee JH, Hwang SY, et al. Factors related to prehospital time delay in acute ST-segment elevation myocardial infarction. J Korean Med Sci. 2012; 27(8):864–869. PMID: 22876051.
20. Ekundayo OJ, Saver JL, Fonarow GC, Schwamm LH, Xian Y, Zhao X, et al. Patterns of emergency medical services use and its association with timely stroke treatment: findings from Get With the Guidelines-Stroke. Circ Cardiovasc Qual Outcomes. 2013; 6(3):262–269. PMID: 23633218.
21. Fladt J, Meier N, Thilemann S, Polymeris A, Traenka C, Seiffge DJ, et al. Reasons for prehospital delay in acute ischemic stroke. J Am Heart Assoc. 2019; 8(20):e013101. PMID: 31576773.
22. Kim YS, Park SS, Bae HJ, Cho AH, Cho YJ, Han MK, et al. Stroke awareness decreases prehospital delay after acute ischemic stroke in Korea. BMC Neurol. 2011; 11(1):2. PMID: 21211051.
23. Moser DK, Kimble LP, Alberts MJ, Alonzo A, Croft JB, Dracup K, et al. Reducing delay in seeking treatment by patients with acute coronary syndrome and stroke: a scientific statement from the American Heart Association Council on cardiovascular nursing and stroke council. Circulation. 2006; 114(2):168–182. PMID: 16801458.
24. Canto JG, Zalenski RJ, Ornato JP, Rogers WJ, Kiefe CI, Magid D, et al. Use of emergency medical services in acute myocardial infarction and subsequent quality of care: observations from the National Registry of Myocardial Infarction 2. Circulation. 2002; 106(24):3018–3023. PMID: 12473545.
25. Choi SW, Shin SD, Ro YS, Song KJ, Lee YJ, Lee EJ. Effect of emergency medical service use and inter-hospital transfer on time to percutaneous coronary intervention in patients with ST elevation myocardial infarction: a multicenter observational study. Prehosp Emerg Care. 2016; 20(1):66–75. PMID: 26727340.
26. Mathews R, Peterson ED, Li S, Roe MT, Glickman SW, Wiviott SD, et al. Use of emergency medical service transport among patients with ST-segment-elevation myocardial infarction: findings from the National Cardiovascular Data Registry Acute Coronary Treatment Intervention Outcomes Network Registry-Get with the Guidelines. Circulation. 2011; 124(2):154–163. PMID: 21690494.
27. Sheth KN. Early transfer of patients with stroke to comprehensive centers is necessary. Stroke. 2014; 45(12):3748–3749. PMID: 25388421.
28. Goyal M, Menon BK, Wilson AT, Almekhlafi MA, McTaggart R, Jayaraman M, et al. Primary to comprehensive stroke center transfers: appropriateness, not futility. Int J Stroke. 2018; 13(6):550–553. PMID: 29508654.
29. Wein TH, Staub L, Felberg R, Hickenbottom SL, Chan W, Grotta JC, et al. Activation of emergency medical services for acute stroke in a nonurban population: the T.L.L. Temple Foundation Stroke Project. Stroke. 2000; 31(8):1925–1928. PMID: 10926958.
Full Text Links
  • JKMS
export Copy
  • Twitter
  • Facebook
Similar articles
Copyright © 2024 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: koreamed@kamje.or.kr